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RN Clinical Auditor
R041123 Thank you for considering a career at Ensemble! Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose:
- Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.
- Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.
- Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.
- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits
- Career Advancement
- This position pays between $63,100.00 - $108,900.00 based on experience
- Have in-depth knowledge of clinical nursing practices and clinical procedures. And an understanding of medical coding and billing (DRG, CPT, ICD-10) along with an understanding of CMS rules and regulations concerning governmental audits including knowledge of CMS polices, Local Coverage Determinations, National Coverage Determinations, and Billing Articles and ability to review within electronic medical records.
- Review medical records to ensure compliance with healthcare standards and regulations
- Validate accuracy and appropriateness of services given
- Record audit determinations using Ensemble Health Partners audit tracking system and document
- Preparing the necessary materials for an audit response.
- Collecting all relevant patient medical records that are requested for the audit
- Make sure all documents are complete, accurate, and signed by the appropriate healthcare providers
- Review the documentation to ensure it complies with Medicare (or payer) requirements.
- On bulk audits, such a TPE and cost outlier, promptly respond to any Notices of Review and requests for additional documentation
- Other tasks mentioned in the job summary.
- Analyze medical records and data to identify trends and discrepancies. Hold strong problem-solving skills to address governmental audit and compliance issues. Keen eye for detail to ensure accuracy in audits and documentation. Thoroughness in reviewing patient charts and medical records.
- Analyze data to identify trends, discrepancies, and areas needing improvement.
- Assist Clinical Audit Nurse Manager and Supervisor with detailed information on audit findings for reporting purposes
- Work effectively with healthcare providers, management, and other departments. And strong interpersonal skills to facilitate teamwork and cooperation. Excellent verbal and written communication skills for reporting findings. Ability to educate and train healthcare staff on best practices and regulations. Participate and communicate during Governmental Audit Client Education Sessions
- Work closely with other healthcare professionals to implement changes and improvements based on audit findings.
- Contact physicians, government auditors, commercial auditors and insurance plans to determine reasons claims were denied
- Provide educational points and resources to healthcare staff on current best practices, policies, and regulations.
- Attend one-on-one education sessions provided by the MAC to understand the audit findings and learn how to correct any identified issues. Provide feedback to client and Ensemble departments (coding, CDI, and RI) and assist in developing action plans
- Understanding of healthcare regulations and standards (Medicare, Medicaid). And stay updated with changes in healthcare laws and guidelines
- Participate in the development of clinical guidelines and protocols to ensure the highest quality of Clinical Audit reviews, and prevention of Clinical Audit audits.
- Assist with quality assurance functions such as development of auditing and educational guidelines as needed
- Stay updated with changes in healthcare regulations and standards, ensuring these changes are implemented in the healthcare facilities
- 2+ years of regulatory audit experience, utilization review, clinical validation, denials or case management experience strongly preferred
- Experience in hospital operations, chart audit/review, and clinical education
- Ability to manage time, meet audit deadlines, and handle multiple tasks.
- Experience working in a production-based work environment
- Flexibility to adapt to changing regulations, work multiple assigned audit tasks and healthcare environments. Ability to work independently and manage workload.
- Ability to evaluate complex situations and make informed decisions.
- Familiarity with electronic medical records (EMR) systems.
- Experience using multiple software programs and tools.
- Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.
- This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.
- Associates or Bachelors Degree in Nursing
- Registered Nurse (RN)
- Innovation
- Work-Life Flexibility
- Leadership
- Purpose + Values
- Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
- Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
- Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
- Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.
